Collectivizing rescue obligations in bioethics

Bioethicists invoke a duty to rescue in a wide range of cases. Indeed, arguably, there exists an entire medical paradigm whereby vast numbers of medical encounters are treated as rescue cases. The intuitive power of the rescue paradigm is considerable, but much of this power stems from the problematic way that rescue cases are conceptualized-namely, as random, unanticipated, unavoidable, interpersonal events for which context is irrelevant and beneficence is the paramount value. In this article, I critique the basic assumptions of the rescue paradigm, reframe the ethical landscape in which rescue obligations are understood, and defend the necessity and value of a wider social and institutional view. Along the way, I move back and forth between ethical theory and a concrete case where the duty to rescue has been problematically applied: the purported duty to regularly return incidental findings and individual research results in genomic and genetic research.

The Right Not to Know and the Duty to Tell: The Case of Relatives

Obtaining and sharing genetic information when there is a potential conflict of interest between patients and their relatives give rise to two questions. Do we have a duty to find out our genetic predispositions for disease for the sake of our relatives, or do we have a right to remain ignorant? Do we have a duty to disclose our known genetic predispositions for disease to our relatives? I argue that the answer to both questions is yes, but to a lesser extent than sometimes claimed.

"Obligated aliens": recognizing sperm donors' ethical obligation to disclose genetic information

Sperm donors' obligations are typically constrained to the immediate circumstances surrounding the donation and to its time frame. This paper makes the case for recognizing an ongoing ethical obligation that binds sperm donors to disclose, in a timely manner, meaningful genetic information to recipients and donor-conceived children. The paper delineates and conceptualizes the suggested (potentially reciprocal) duty and argues that it is not the genetic link between the donor and the donor-conceived child that binds donors by said duty, but rather social responsibility. Accordingly, an original perception of the donor as an obligated alien is suggested and developed. The main thesis of the paper is supported inter alia by a comparison between transmitting infectious diseases and passing faulty genes on to donor-conceived children. The paper also provides an in-depth analysis of the conflicting interests of the parties generated by such an obligation and proposes a model for embedding this ethical duty in a (legal) contractual framework.

The ethics of contacting family members of a subject in a genetic research study to return results for an autosomal dominant syndrome

This case explores the ethical landscape around recontacting a subject's relatives to return genetic research results when the informed consent form signed by the original cohort of subjects is silent on whether investigators may share new information with the research subject's family. As a result of rapid advances in genetic technology, methods to identify genetic markers can mature during the life course of a study. In this case, the investigators identified the genetic mutation responsible for the disorder after a number of their original subjects had died. The researchers now have the ability to inform relatives of the subject about their risk of developing the same disease. Mark Rothstein, JD, from the University of Louisville School of Medicine, provides an overview of the medical/scientific, legal, and ethical issues underlying this case. Lauren Milner, PhD, and colleagues at Stanford University explore how the relationship between researcher and subject affect this debate. Seema Shah, JD, and colleagues at the National Institutes of Health and University of California, Los Angeles (UCLA) discuss whether and how requirements of the duty to warn are applicable in this case.

Medical confidentiality and partner notification in cases of sexually transmissible infections in Belgium

Research has shown that HIV-positive patients sometimes refuse to take precautionary measures against sexual transmission as well as to notify their sexual partner(s) of their status. Faced with such a situation, physicians find themselves in a dilemma as they are forced to choose between honouring their duty of professional confidentiality and protecting their patients' partner(s). Recent advice from the Belgian Medical Council (BMC) for the first time accepts that physicians can exceptionally, and under certain conditions, invoke necessity to breach confidentiality and inform usual and occasional sexual partners of HIV-infected patients who refuse to take precautions against transmission. This article sketches the ethical evolution of this position from 1987 up to now in Belgium, and examines whether or not the BMC's opinion on the matter corresponds to the applicable substantive criminal law provisions and whether or not partner notification could also be defended for other sexually transmissible infections (STIs). A case study of the situation in Belgium illustrates how discussions about STIs can deeply influence the evolution of legal and ethical rules about medical confidentiality.

Surgeon-patient information disclosure practices in southwestern Nigeria

OBJECTIVE

This study examined the practice of information disclosure to patients by surgeons in Nigeria.

SUBJECTS AND METHODS

A 55-item self-administered semi-structured questionnaire was sent to 150 surgeons in southwestern Nigeria in 2004-2005. The data obtained from the completed questionnaire were analyzed using descriptive statistics.

RESULTS

Of the 150 surgeons, 102 completed the questionnaire, giving a response rate of 68.0%. Of these 102, 85 (85.3%) were men, 44 (43.1%) were consultants and 55 (54.0%) were senior and junior surgical trainees. Most were from surgical subspecialties and obstetrics and gynecology. A documented policy statement about information disclosure was not available in most hospitals. A third, i.e. 35 (34.3%), of the surgeons did not routinely engage patients in discussions about disease diagnosis, management and prognosis. Most, i.e. 73 (71.6%), would rather disclose worsening disease progression to the patient's spouse. Others would disclose such information to the patient's children, family members or clergy. This was presumably to shield the patient from psychological distress. Only 22 (21.6%) of them routinely disclose operative findings to patients or their families. Thirty (29.4%) of them had been involved in disclosing medical errors to their patients in the past while 63 (61.8%) respondents did not know if surgical errors with potentially negative consequences should be disclosed.

CONCLUSION

Most of the surgeons in southwestern Nigeria did not routinely provide detailed information to patients about their illness and possible outcome of illness even in the presence of worsening disease progression and prognosis. When surgical errors with potential negative consequences occurred, the majority did not know if such errors should be disclosed.

Tarasoff duties in prisons: community standards with certain twists

Because inmates' actions are restricted by incarceration, Tarasoff duties in prisons have certain unique aspects. There are two broad situations: (1) when the potential victim is located within the prison community; and (2) when the potential victim is located outside of prison. Although responsibilities vary widely from state to state, this paper discusses general principles of exercising Tarasoff duties in prison settings. In addition to duties to protect potential victims, correctional mental-health professionals have an ethical duty to protect patient confidentiality. Professionals should chose Tarasoff options that protect confidentiality to the fullest extent possible, and prisoners should be informed of situations where confidentiality does not exist. A caveat is that no Tarasoff statutes can be relied upon to offer tort protection to correctional clinicians until they have been tested in appellate courts.

HIV diagnosis disclosure: stigma management and stigma resistance

This article reports diagnosis disclosure decision comments arising serendipitously in five focus group discussions with 34 HIV-infected New Yorkers over age 50. Three overarching disclosure themes demonstrate the complexity of diagnosis disclosure decision-making: (a) hiding or selectively disclosing, or stigma management; (b) partial disclosure because of the perception of partial control of the information; and (c) widespread or complete voluntary diagnosis disclosure, representing stigma resistance. Social workers and other human services practitioners should remember the diversity in the HIV population, the aging population, and the HIV-positive aging population. Experiences of HIV stigma and choices about diagnosis disclosure and stigma management or resistance are individual, reciprocal, and dynamic.

Stem cell tourism and doctors' duties to minors--a view from Canada

While the clinical promise of much stem cell research remains largely theoretical, patients are nonetheless pursuing unproven stem cell therapies in jurisdictions around the world--a phenomenon referred to as "stem cell tourism." These treatments are generally advertised on a direct-to-consumer basis via the Internet. Research shows portrayals of stem cell medicine on such websites are overly optimistic and the claims made are unsubstantiated by published evidence. However, anecdotal evidence suggests that parents are pursuing these "treatments" for their children, despite potential physical and financial risk. Physicians are in a unique position as they can be expected to be involved in, or privy to, such decisions. In this paper, we consider what duties physicians may have toward minor patients whose parents/guardians wish to engage in stem cell tourism on their behalf. We use the Canadian perspective to address the broadly relevant issues raised by this trend.